Routine inspection·August 30, 2021

On 8/30/21 Licensing Program Analyst (LPA) Praveen Singh arrived unannounced to conduct an annual required inspection utilizing the infection control domain. LPA met with Administrator and explained the purpose of the inspection. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Facility Representative and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. LPA toured the facility including but not limited to living room, dining room, kitchen, bathroom, and resident rooms. Medications are centrally stored in a locked area that is inaccessible to clients and refilled every 30 days. Facility has enough 2-day perishable food and 7-day non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a mitigation plan. LPA and Administrator completed the infection control domain. See LIC809-C for continued report LPA observed the following violations during inspection: LPA observed that facility has a sign-in policy with only names and dates of visitors, however symptom screening information is not logged. Facility does not document daily temperature and COVID-19 symptom checks, and/or any change in condition for staff and residents in order to track spread and why facility took certain steps to prevent and mitigate spread in the facility. LPA observed S2 did not wash her hands after using the restroom. LPA observed cockroaches in vacant resident room, in R2's room, in hallway, bathrooms and other living space areas. Updated copies of the following documents were requested for facility file and are to be sent to CCL by 09/7/21: • LIC500- Personnel Report • LIC308- Designation of Facility Responsibility • LIC610E- Emergency/Disaster Plan • Evidence of Liability Insurance Deficiencies cited from California Code of regulations, Title 22, and citations are listed on the attached LIC809-D. If the deficiency is not corrected by the noted due date civil penalties may be assessed. Exit interview conducted and appeal rights provided.